Perspective: Why Nephrology Needs a Blockbuster Therapeutic

"So what motivates medical students prior to, during and following their formal training? I believe this centers on a dedication to helping people by integrating science and medicine, and delivering a product consisting of diagnostic and therapeutic options, understanding and empathy."  Dr. Molitoris

"So what motivates medical students prior to, during and following their formal training? I believe this centers on a dedication to helping people by integrating science and medicine, and delivering a product consisting of diagnostic and therapeutic options, understanding and empathy."  Dr. Molitoris


Multiple factors have been described as contributors to the declining lack of interest in a nephrology career. These range from too intellectually challenging to income and life style considerations. However, I believe we are not considering a basic premise of why individuals choose a career in health care.

The pursuit of a career in medicine is a long, demanding and arduous road. Medical school, residency and, for the majority, fellowship training means the individual is deeply committed to a career of helping people. These individuals are intelligent, hardworking and proven worthy by academic and community related performances in college. They realize careers in medicine continue to be challenging careers with continuous educational demands and long hours, weekend call schedules and after hour calls. Therefore, it is far more than superficial needs such as financial and lifestyle considerations that motivate these students.

So what motivates medical students prior to, during and following their formal training? I believe this centers on a dedication to helping people by integrating science and medicine, and delivering a product consisting of diagnostic and therapeutic options, understanding and empathy. Students also value respect from their communities and by their peers.  Interestingly, these two needs, care delivery and respect, are distinct entities and vary according to one’s own values as a physician. For instance, a family care physician’s reward system values community and individual patient respect, while specialists likely value peer respect at a higher level.

Given this hypothesis, let’s examine what determines community and peer respect. Community respect is engendered by the ability to provide care that is understood by the consumer, deemed relevant, progressive and beneficial in nature. To accomplish this the consumer must be educated as to the importance of the specialty and the diseases treated.  This often involves direct experience within the family or social network of the area in question. It also relates to grass root education of and marketing to the consumer. Take, for instance, cancer, myocardial infarction and hypertension.  These diseases have community names: cancer, heart attack and high blood pressure, that carry a well-appreciated prognosis to the general population.  They have consumer recognizable, life-changing outcomes, symptoms and/or signs of disease, and substantial diagnostic and therapeutic progress has been made in their treatment.  The community easily recognizes cholesterol as a marker of coronary artery disease, high blood pressure as a leading cause of cerebral vascular accidents and the need for cancer screening.  This consumer recognition of disease importance, and the unmet need, has led to grass roots support for increased NIH funding and pharmaceutical investments, respectively.

Now let’s look at nephrology as a discipline.  The American Society of Nephrology, the premier health care society in the nephrology field, is 50 years old this year. Nephrology have always provided physicians in training with intellectually stimulating physiology, biochemistry, molecular biology and histology. Discovery has always been the central issue in nephrology and translation, except for dialysis, has unfortunately taken a back seat. In particular, techniques and diagnostics in nephrology have lagged behind other areas of medicine subspecialties such as cardiology, Gastroenterology, Pulmonary or fields like Radiology, OB-GYN, Critical Care and Oncology. This lack of diagnostics has limited the ability to individualize care and, I believe, the inability to develop targeted therapies that change the course of a disease.  Major advances have occurred in nephrology, including dialysis and the use of renin-angiotensin blockers, but these are now in the distant past and the luster that interested my generation has diminished. 

More importantly, does the consumer and medical student know the importance of these advances and the large unmet need in nephrology?  Does the consumer know the incidence and prevalence of chronic kidney disease is the same as hypertension and diabetes?  Is there a well appreciated sign or symptom or marker of kidney disease that is known to the public?  Do members of the US Congress, or the starting medical student, know what Nephrology is and what a nephrologist does?  If they do know, it is all too often limited to their role in chronic dialysis and not all the other areas of medical service.

So what is the remedy for this conundrum?  I believe it starts with a grassroots movement to educate the general population about the kidney, it’s diseases and why they should care about these diseases.  This is exactly where a blockbuster therapeutic is essential.  For instance, a blockbuster therapeutic for diabetic nephropathy could drive a revolution in consumer education, primarily by the marketing necessity of identifying and educating the population that would benefit.  This financial investment in consumer education is expensive and there must be an end game to make it happen.  The National Kidney Foundation has tried to educate patients affected by kidney disease, dialysis and CKD patients, but has had a more limited approach to educating the general population. ASN has recognized the need for patient advocacy on Capitol Hill, and has worked with a range of patient groups to try to encompass all areas of kidney disease and help patients lead the Capitol Hill agenda. T he number of patients requiring dialysis for life support is smaller in population terms, always an important consideration in Congress.  This would not be true for the 8-10% of the general population that has CKD.

For medical students, blockbuster drugs often highlight disease areas before and during formal training. The development of new diagnostics to individualize care would generate interest and enhance the necessity of the nephrologist in the care cycle.  More importantly, students would know they are helping people with a severe and treatable disease.  This is extremely important: it is why they went into Medicine in the first place.  Recent interest in Rheumatology serves as an example of the importance attached to benefiting the patient.  For many years the number of candidates for Rheumatology fellowship was less than the number of training slot available.  However, with the introduction of immune therapy for rheumatoid arthritis, interest in treating these patients blossomed, and applications far exceeded the number of training positions available.  The extent this increase interest relates to reimbursement possibilities or the ability to help individuals with a chronic debilitating disease remains to be determined. 

I also believe there is a trend toward minimizing the need for nephrologists to dialysis care.  Take, for instance, the increasing role of the hospitalist in teaching and prescribing volume, acid-base and electrolyte diagnostics and therapies. Given that many, if not the majority of, hospitalists have had minimal formal training in nephrology, does this make sense from a care or education point of view?  Endocrinologists are now asked to consult on hyponatremia cases; Cardiologists lead many contrast nephropathy studies, and Critical Care physicians around the world provide continuous renal replacement therapies to ICU patients.  The role of the Nephrologist in the care of the hospitalized patients should be expanding; it is contracting.  This also results in a  lack of exposure between nephrologists and medical students, yet another factor that limits the student’s education about the importance of nephrology and limits the opportunity to see nephrologists as role models.

To end on a more positive note, kidney transplantation and the diagnosis and care of glomerular diseases are areas of exciting diagnostic and therapeutic success in nephrology.  Many of us have changed our medical student and resident consult rotations to emphasize these areas and the importance of the nephrologist in the care of these patients.  Now we must take what we have learned from these areas and move forward with development of additional diagnostics that individualize and advance therapeutic care for the patients we serve.